Effects of assisted outpatient treatment and health care services on psychotic symptoms

Client Outreach in Los Angeles County's Assisted Outpatient Treatment Program: Strategies and Barriers to Engagement

Purpose

Assisted Outpatient Treatment (AOT) programs can compel treatment-refusing individuals to participate in mental health treatment via civil court order. In California's AOT programs, individuals first must be offered 30 days of outreach services and can accept services voluntarily. This study examines the use of outreach strategies in an AOT program with the potential for voluntary or involuntary enrollment.

Methods

Outreach staff completed a survey in which they reported and rated outreach strategies and barriers to treatment for 487 AOT-referred individuals.

Results

Outreach staff reported using a broad array of strategies to persuade and engage clients. Supportive and persuasive strategies were most common. More coercive strategies, including court order, were used when needed. More clients enrolled voluntarily (39.4%) than involuntarily (7.2%).

Conclusions

Outreach, coupled with the strategic used of potential court involvement, can lead to voluntary enrollment of treatment-refusing individuals with many, often severe, barriers to engaging in outpatient treatment.

Experiences with legally mandated treatment in patients with schizophrenia: A systematic review of qualitative studies

Background:

Patients with severe mental illness, including schizophrenia, may be legally mandated to undergo psychiatric treatment. Patients’ experiences in these situations are not well characterized. This systematic review of qualitative studies aims to describe the experiences of patients with schizophrenia and related disorders who have undergone legally mandated treatment.

Methods:

Four bibliographic databases were searched: CINAHL Plus (1981–2019), EMBASE (1947–2019), MEDLINE (1946–2019), and PsycINFO (1806–2019). These databases were searched for keywords, text words, and medical subject headings related to schizophrenia, legally mandated treatment and patient experience. The reference lists of included studies and systematic reviews were also investigated. The identified titles and abstracts were reviewed for study inclusion. A thematic analysis was completed for the synthesis of positive and negative aspects of legally mandated treatment.

Results:

A total of 4,008 citations were identified. Eighteen studies were included in the final synthesis. For the thematic analysis, results were collated under two broad themes; positive patient experiences and negative patient experiences. Patients were satisfied when their autonomy was respected, and dissatisfied when it was not. Patients often retrospectively recognized that their treatment was beneficial. Furthermore, negative aspects of the treatment included deficits in communication and a lack of information.

Conclusions:

Intervention research has historically focused on clinical outcomes and the quantitative aspects of treatment. Thus, this study provides insight into the qualitative aspects of patients’ experiences with legally mandated treatment. Recognizing these opinions and experiences can lead to better attitudes toward treatment for patients with schizophrenia and related psychiatric illnesses.

Outpatient commitment in mental health services from a municipal view

BACKGROUND

Outpatient commitment (OC) is a legal decision for compulsory mental health care when the patient stays in his or her own home. Municipal health-care workers have a key role for patients with OC decision, but little is known about how the legislation system with OC works from the municipality's point of view.

METHOD

The present study has a quantitative descriptive design using an electronic questionnaire sent to health-care workers in the municipalities that participated. The study included health-care workers from the mental health services in two counties in Norway who have experience with psychosis and OC decisions.

RESULTS

There were 230 people who received the questionnaire. The sample consisted of various health professionals from both small and large municipalities.The results show which tasks they have in follow-up of patients in the municipalities.

CONCLUSION

From the municipality's point of view, there are no significant differences in follow-up for patients with or without an OC decision, apart from conversations about medication. An individual plan is rarely used to facilitate follow-up, although this is the statutory right of patients with OC decisions. The health-care workers lack knowledge and education about the OC scheme. The cooperation between municipalities and the specialist health-care services is not clearly defined.

Compulsory Admission to Psychiatric Wards-Who Is Admitted, and Who Appeals Against Admission?

Background: When persons with a mental illness present a danger to themselves or others, involuntary hospital admission can be used to initiate an immediate inpatient treatment. Often, the patients have the right to appeal against compulsory admission. These processes are implemented in most mental health-care systems, but regulations and legal framework differ widely. In the Swiss canton of Basel-Stadt, a new regulation was implemented in January 2013. While the current literature holds some evidence for factors associated with involuntary admission, knowledge on who uses the right to appeal against admission is sparse. Aims: The study aims to examine if specific sociodemographic and clinical characteristics are associated with involuntary admission and with an appeal against the compulsory admission order. Method: Routine clinical data of all inpatient cases admitted during the period from January 2013 to December 2015 at the Psychiatric University Hospital Basel were extracted. Generalized estimating equation (GEE) analyses were used to examine the association of sociodemographic and clinical characteristics with "involuntary admission" and "appeal against compulsory admission order." Results: Of the 8,917 cases included in the present study, 942 (10.6%) were admitted involuntarily. Of these, 250 (26.5%) lodged an appeal against the compulsory admission order. Compared with cases admitted on a voluntary legal status, cases admitted involuntarily were older and were admitted more often during the nighttime or weekend. Moreover, involuntarily admitted cases had more often a principal diagnosis of a schizophrenia spectrum disorder. Patients from cases where an appeal was lodged were more often female, had more often Swiss nationality, and were more often diagnosed with schizophrenia spectrum disorder. Conclusion: Despite legal changes, the frequency of involuntary admissions in the observed catchment area seems to be relatively stable across the last 20 years. The percentage of appeals has decreased from 2000 to 2015, and only comparably few patients make use of the possibility to appeal. Better knowledge of the regulations, higher social functioning, and lower insight into illness might be associated with a higher probability of lodging an appeal. Future research should examine if specific patient groups are in need of additional assistance to exert their rights to appeal.

Update on Assisted Outpatient Treatment

PURPOSE OF REVIEW

Assisted outpatient treatment (AOT) is an outpatient court-ordered treatment for people with severe mental illness (SMI) whose care needs are often unmet in the community due, in part, to treatment non-adherence. AOT is controversial, and the goal of this review is to provide an update on recent research, the status of AOT in the United States, and future directions for research and implementation.

RECENT FINDINGS

Several recent studies have demonstrated that it is not just a lack of access to appropriately intensive care that prevents some individuals with SMI from engaging in and benefiting from treatment and that AOT can improve engagement and patient outcomes over and above the provision of care. The future of AOT in the United States is still somewhat uncertain and will largely depend on the effectiveness and sustainability of the SAMHSA AOT grant programs. Future research efforts should investigate the conditions under which and for whom AOT can be most effective, to help avoid poor outcomes for this vulnerable population.

Cross-Cultural Notions of Risk and Liberty: A Comparison of Involuntary Psychiatric Hospitalization and Outpatient Treatment in New York, United States and Zurich, Switzerland

Involuntary hospitalization is a frequently discussed intervention physicians must sometimes execute. Because this intervention has serious implications for the citizens' civil liberties it is regulated by law. Every country's health system approaches this issue differently with regard to the relevant laws and the logistical processes by which involuntary hospitalization generally is enacted. This paper aims at analyzing the regulation and process of involuntary hospitalization in New York (United States) and Zurich (Switzerland). Comparing the respective historical, political, and economic backgrounds shows how notions of risk and liberty are culture-bound and consequently shape legislation and local practices. It is highly relevant to reconsider which criteria are required for involuntary hospitalization as this might shape the view of society on psychiatric patients and psychiatry itself. Furthermore, this article discusses the impact that training and experience of the person authorized to conduct and maintain an involuntary hospitalization has on the outcome.